By: Elaine K. Howley
Many women undergo a breast reconstruction after having a lumpectomy or mastectomy as part of their breast cancer treatment. Choosing whether to do so is a highly personal decision, but one that women are increasingly selecting. According to a 2014 study in the Journal of Clinical Oncology, “reconstruction use increased from 46 percent in 1998 to 63 percent in 2007.”
Although the reconstruction trend is apparently upward, you don’t have to reconstruct the breast if you don’t want to. Some women opt to “live flat” for a range of reasons, preferring to avoid additional surgery or potential complications. For others, reconstructing the breast and getting their figure back to “normal” as quickly as possible is a priority. Patients can opt to have an immediate reconstruction at the time of the mastectomy, or they can come back later after everything has healed for a delayed reconstruction.
If you do opt for breast reconstruction, you’ll have several decisions to make, though some of these may be made for you by your doctor depending on the type and stage of your cancer, your overall health and other factors.
Types of Reconstruction
Babak Mehrara, chief of plastics and reconstructive services at the Memorial Sloan Kettering Cancer Center in New York, says, “broadly speaking, you can do reconstruction in one of two ways. You can have it with implants or with your own tissues.” In some instances a combination of tissue and implant may also be used. Fat grafting, a procedure in which fat is removed from another area of the body, liquefied and then injected into the breast area is a newer procedure that’s gaining attention, Breastcancer.org reports. But the long-term results of this less invasive reconstruction approach are still unclear.
Autologous or flap reconstructions are procedures in which the breast shape is formed from tissue gathered from other places on the patient’s own body, thus lowering the chances of rejection or infection because the patient’s own tissue is used. “We take skin and fat where you have a little extra,” Mehrara says. “Most commonly we take it from the lower portion of the belly, but sometimes we take it from the inner thigh, upper buttock, the back or other areas, and then we transfer that tissue to the breast and use that to replace the volume of the breast.” Patients generally spend three to four nights in the hospital and the recovery time is usually about four to eight weeks depending on the specific type of procedure.
“The advantages of using your own tissue is it’s your own tissue,” Mehrara says. “It’s soft, it’s natural,” and it changes with you. If you gain or lose weight, the reconstructed breast will change, too, “unlike with an implant that doesn’t change with the patient.” It’s also easier to treat any infections that could develop, because your own blood supply can deliver the needed antibiotics to the site of the infection. And, with autologous reconstructions, the patient only undergoes one large surgery. Mehrara says reconstructing a breast typically takes six to seven hours. “For both sides, it’s about 8 to 10 hours.” He describes the procedure as “delicate” and time consuming, “but at this point it’s a routine, complicated operation.”
On the downside, you’ll be left with a large scar at the site where the tissue was harvested where there’s also a risk of bleeding and infection. Mehrara says the risk of a blood clot developing in one of the reattached blood vessels during a free flap reconstruction is “the thing we worry about most,” but it only happens about two percent of the time and the risk of blood clot is highest in the first week. “Every hour that goes by, the risk goes down. Usually after the first three or four days, we stop worrying about it,” he says.
Although Mehrara says most long-term satisfaction surveys indicate that patients who elect autologous reconstructions are happier with their results, implant reconstructions are more popular, likely in part because this approach requires less surgery as there is no tissue to be transferred. Implants are balloon-like structures filled with saline (salt water) or silicone that are used to create the volume of the missing breast. Mehrara says he thinks silicone implants offer a more natural feel and that concerns about their safety that increased to a near fever pitch in the 1980s have not turned out to be warranted. Still, all implants have the potential to rupture.
During an immediate reconstruction using an implant, Mehrara says the breast surgeon will conduct the mastectomy and then the plastic surgeon comes in to insert an expander. “The expander is really a temporary implant that has a port built into it that allows us to adjust the size,” he says. The expander is slipped under the chest muscle, which helps protect it from infection and helps keep it in place.
With the expander implanted, the patient is sent home to recover but then returns to see the plastic surgeon several times over the next few weeks or months to have saline injected into the expander. This is done incrementally over time to stretch the muscle and skin to create a pocket for the permanent implant that will be surgically inserted later. “Most patients need about three or four expansions,” Mehrara says, which “can be done as often as weekly or can be spread out over a period of time.”
Although expanders have typically required saline injections to work, a new air-based expander device was recently approved by the FDA and may become more widely available. Jeffrey Ascherman, professor of surgery at Columbia University and site chief of the division of plastic surgery at the New York-Presbyterian University Hospital of Columbia and Cornell, was principal investigator on a recent clinical trial of the expander device, called AeroForm. It’s implanted like a regular expander but includes a hand-held controller that connects with “a little cartridge of compressed CO2 inside the expander. When you press the button, it releases a very small dose of CO2 inside the expander. But because it can be done by the woman, she can do it several times a day as opposed to coming to my office every few weeks. It ends up being a much quicker process,” Ascherman says. He also notes this “is the first real advance in tissue expansion in 40 or 50 years. ”
No matter which expander is used, once the skin and muscle have been stretched to the right size, the patient comes in for a second operation to have the expander removed and the permanent implant inserted. Mehrara says he usually waits about four months between the two surgeries. The second surgery “isn’t complicated, it takes about an hour to do. And the recovery time is the same as the mastectomy.” He says most patients spend one night in the hospital after implant surgery. Typically, the patient will return for a third operation a few months later for nipple reconstruction, where skin on the breast is shaped into a nipple and then a tattoo or skin graft is used to create the areola.
Although the recovery period may be shorter, implant reconstruction can result in some complications, the most common being a condition called capsular contracture. “It’s a fancy word for scar tissue,” Mehrara says. The body forms a layer of scar tissue around the implant in an attempt to protect the body from the implant, which is normal. But if the capsule thickens, that can “make the implant feel tight, uncomfortable, painful, and make it look funny by pushing it up.”
Infection of the implant can also be an issue in some cases. Because the implant is foreign material that’s not fed by the blood system, if bacteria gets onto the implant itself, it can be very difficult to eliminate, and the implant may have to be removed or replaced.
In addition, Mehrara says “implants don’t last forever. They last about 10 to 20 years, so we have to change them at some point in most patients.” Patients with silicone implants will likely need to have an MRI every three to five years to check for leakage, “and that is a little bit of an inconvenience for some people.”